Improvised explosive device-related lower genitourinary trauma in current overseas combat operations

Urology during Afghanistan mission: lessons learned and implications for the future

PURPOSE

Battle-related trauma is common in modern warfare and can lead to genitourinary injuries. In Western countries, urogenital injuries are rare in the civilian environment. The main objective of this study was to assess urological workload for surgeons on deployment.

MATERIAL AND METHODS

Data were acquired over a period of five years of deployment in a U.S. facility in Afghanistan.

RESULTS

German urological surgeons treated on average one urologic outpatient per day and performed 314 surgical interventions overall. Surgical interventions were categorized as battle-related interventions (BRIs, n = 169, 53.8%) and nonbattle-related interventions (non-BRIs, n = 145, 46.2%). In the BRI group, interventions were mainly performed on the external genitalia (n = 67, 39.6%), while in the non-BRI group, endourological procedures predominated (n = 109). This is consistent with a higher rate of abdominal or pelvic procedures performed in the BRI group (n = 51, 30.2%). Furthermore, the types of interventions performed on the external genitalia differed significantly. In the BRI group, 58.2% (n = 39) of interventions were scrotal explorations, but none of those procedures were performed in the non-BRI group (p < 0.001). However, 50.0% (n = 13) of scrotal explorations in the non-BRI group were due to suspected torsions of the testes followed by orchidopexy (BRI: n = 1, 1.5%, p < 0.001). Concerning outpatients, the consultation was mainly due to complaints concerning the external genitalia (32.7%, n = 252) or kidney/ureteral stones (23.5%, n = 181).

CONCLUSION

While the treatment of urological outpatients in a deployment setting resembles the treatment of soldiers in Germany, BRIs requires abdominal/retroperitoneal urosurgical skills and basic skills in reconstructive surgery.

Male Genitourinary Injuries in Combat - A Review of United States and British Forces in Afghanistan and Iraq: 2001-2013

As we look to the current conflict in Ukraine, our service members deploy to periphery Northern Atlantic Treaty Organization countries. At the same time, we see an increase in high-kinetic wounding patterns in the United States. We look to the important underrepresented topic of urologic trauma in combat casualties to prepare for the wounds of modern warfare. Genitourinary wounds are increasingly frequent and affect both military and civilian casualties; civilian urologists and deployed surgeons require proficiency in treating these wounds. We present this review of urologic trauma in Afghanistan and Iraq to inform considerations for urologic surgeons and first responders.

Male Sexual Health Related Complications Among Combat Veterans

INTRODUCTION

With improved armor and combat trauma care, more male service members in the 21st century are surviving devastating injuries to their genitourinary (GU) system. The impact of these injuries can have long lasting effect on their sexual function and fertility status.

OBJECTIVES

To review the current literature on sexual health-related complications and fertility implications among male service members sustaining combat related injuries.

METHODS

We performed a literature search that included male sexual health complications and combat injuries using PubMed and Google Scholar. We reviewed the impact of traumatic injuries to the pelvis and perineum on sexual function and fertility, and we also discuss sexual dysfunction from posttraumatic stress disorder (PTSD) and traumatic brain injuries (TBI).

RESULTS

Injuries sustained during combat are usually polytraumatic, especially in recent conflicts with improvised explosive devices. The majority of GU combat injuries involve the scrotum, testes, and penis resulting in lasting structural dysfunction. PTSD is associated with higher levels of erectile dysfunction, hypoactive sexual desire, and premature ejaculation. Overall, veterans diagnosed with PTSD had a higher risk of developing sexual dysfunction. Veterans with TBI experience sexual health complications, such as decreased libido, difficulties with arousal maintenance, and the ability to achieve orgasm. Combat related injuries can have significant fertility implications on service members as they typically serve in their peak fertility years.

CONCLUSIONS

Traumatic GU injuries, PTSD, TBI, and associated endocrine dysfunction can all contribute to sexual dysfunction among combat veterans. Given the complex nature of sexual dysfunction in this population, these patients are best managed by a multidisciplinary team. Castillo O, Chen IK, Amini E, et al. Male Sexual Health Related Complications Among Combat Veterans. Sex Med Rev 2022;XX:XXX-XXX.

[Do concomitant urological injuries in severely injured patients lead to poorer outcomes? : A multivariate risk analysis]

BACKGROUND

Severely injured patients with associated genitourinary (GU) injuries have only rarely been investigated in the current literature. If at all, analyses are commonly focussed on renal injuries, marginalising other GU traumas such as ureteral injuries. In this study, we would like to characterise patients with GU injuries and analyse the impact of such injuries on mortality and length of stay.

MATERIALS AND METHODS

The inclusion criteria for this retrospective analysis of TraumaRegister DGU® data were: Injury Severity Score ≥ 16 within the period between 2009 and 2016 with available data on age and length of stay. A descriptive analysis was used to compare patients with and without GU injuries. The impact of GU injuries on mortality and length of hospital stay was evaluated by means of multivariate regression analyses.

RESULTS

In all, 90,962 patients met the inclusion criteria; 5.9% of them had suffered GU injuries (n = 5345). The prevalence in patients with pelvic fractures was up to 19%. On average, patients with GU trauma were 10 years younger (42.9 vs. 52.2 years) and more severely injured (ISS: 31.8 vs. 26.4). The multivariate analyses demonstrated that GU injuries in severely injured patients are no independent risk factor for mortality. However, particularly bladder and genital injuries result in longer hospitalisation.

CONCLUSION

GU injuries do not represent an additional risk factor for mortality. However, after adjusting for established prognosis factors, they can cause prolonged periods of hospitalisation of severely injured patients.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Transitional Care of Service Members With Genitourinary Injury

OBJECTIVE

To improve urotrauma care by describing veterans' current demographics and needs assessment during transitional care to the Veteran Health Administration (VHA) system.

METHODS

We utilized our previously identified cohorts obtained from the DoD Trauma Registry data for male service members injured in theater linked with VHA electronic health records. We included veterans who received care at VHA at least once from October 2001 through September 2011 for chart review. We investigate demographics, opportunities for care, combat-related trauma, disability, and associated mental health or urologic conditions specifically at the initial encounter with a VHA healthcare provider.

RESULTS

We queried 580 veterans' records in VHA from the linked databases. We idenfied that 141 (24.4%) veterans received addional care outside VHA and 17.1% (n = 99) of charts had insufficient data for injury validation. Reference to the urotrauma was mentioned in 72% of VHA initial visits (n = 416/580). The most common urotrauma occurred to the lower/external genitourinary injury (298, 51%). Of all the veterans identified with genitourinary trauma, approximately 28% (n = 160) were referred for urologic consultation, but only 14% were related to the original urotrauma. Ninety percent (522/580) of service members with urotrauma also had a mental health diagnosis, largely post-traumatic stress disorder (PTSD, 70.8%).

CONCLUSIONS

The majority of men with urotrauma did have contact with VHA, yet there is no systematic approach to baseline assessment or long-term care strategy. However, only a small proportion of DoD-documented urotrauma requires ongoing care. We identified that coordinating care with mental health pathways (PTSD/traumatic brain injury) may be an opportunity to evaluate the long-term effects of urotrauma.

Urinary Tract Infections after Combat-Related Genitourinary Trauma

Background: We examined clinical outcomes among combat casualties with genitourinary injuries after blast trauma. Methods: Characteristics, clinical care, urologic complications, and infections for subjects enrolled in the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) sources. Logistic regression identified predictors for urinary tract infections (UTIs) after genitourinary trauma. Results: Among 530 TIDOS enrollees who entered VA care, 89 (17%) sustained genitourinary trauma. The majority of subjects (93%) were injured via a blast and 27% had a dismounted complex blast injury (DCBI). Sexual dysfunction was reported with 36% of subjects, whereas 14% had urinary retention/incontinence and 8% had urethral stricture. Urologic complications were comparable between patients with and without DCBIs. Nineteen (21%) subjects had one or more UTI with a total of 40 unique UTI events (25% during initial hospitalization and 75% during subsequent DOD or VA care). The UTI incidence rate was 0.89 per patient-year during initial hospitalization, 0.05 per patient-year during DOD follow-up, and 0.07 per patient-year during VA healthcare. Subjects with UTIs had a higher proportion of bladder injury (53% vs. 13%; p < 0.001), posterior urethral injury (26% vs. 1%; p = 0.001), pelvic fracture (47% vs. 4%; p < 0.001), soft-tissue infection of the pelvis/hip (37% vs. 4%; p = 0.001), urinary catheterization (47% vs. 11%; p < 0.001), urinary retention or incontinence (42% vs. 6%; p < 0.001), and stricture (26% vs. 3%; p = 0.004) compared with patients with genitourinary trauma and no UTI. Independent UTI risk factors were occurrence of a soft-tissue infection at the pelvis/hip, trauma to the urinary tract, and transtibial amputation. Conclusions: Among combat casualties with genitourinary trauma, UTIs are a common complication, particularly with severe blast injury and urologic sequelae. Episodes of UTIs typically occur early after the initial injury while in DOD care, however, recurrent infections may continue into long-term VA care.

Urethral injury in major trauma

Urethral injury in major trauma is infrequent, with complex problems of diagnosis and treatment. The aims of this study are to determine the incidence and epidemiological factors relating to urethral injury in major trauma, as well as determine if any additional prognostic factors are evident within this cohort of patients. A retrospective review of patients sustaining urethral injury following major trauma was made over a 6-year period, from 2010 to 2015. Quantitative analysis was made using the national trauma registry for England and Wales, the Trauma Audit and Research Network (TARN) database, identifying all patients with injury codes for urethral injury. 165 patients with urethral injuries were identified, over 90% were male, most commonly injured during road traffic accidents and with an associated overall mortality of 12%. Urethral injury in association with pelvic fracture occurred in 136 patients (82%), representing 0.6% of all pelvic fractures, and was associated with double the rate of mortality. Urethral injury was associated with unstable pelvic fractures (LC2, LC3, APC3, VS, CM) but not with a specific pelvic fracture type. This study confirms the rare incidence of this injury in major trauma at 1 per 2 million population per year.

Chinese expert consensus on echelons treatment of pelvic fractures in modern war

The characteristics and treatment of pelvic fractures vary between general conditions and modern war. An expert consensus has been reached based on pelvic injury epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. According to this consensus, first aid, emergency treatment and early treatment of pelvic fractures are introduced in three separate levels. In Level I facilities, simple triage and rapid treatment following the principles of advanced trauma life support are recommended to evaluate combat casualties during the first-aid stage. Re-evaluation, further immobilization and fixation, and hemostasis are recommended at Level II facilities. At Level III facilities, the main components of damage control surgery are recommended, including comprehensive hemostasis, a proper resuscitation strategy, the treatment of concurrent visceral and blood vessel damage, and battlefield intensive care. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Total penile reconstruction: A systematic review

BACKGROUND

Phalloplasty poses a unique challenge to the plastic and reconstructive surgeon. The development of advanced microsurgical techniques has greatly augmented the range of surgical approaches available.

METHODS

A systematic review of the MEDLINE and Cochrane databases was performed to identify clinical studies of total penile reconstruction published within the last 10 years using the search algorithm: "(phallus or penis or penile) and (reconstruction or phalloplasty or transplant)".

RESULTS

The primary literature search retrieved 1400 articles. After applying inclusion and exclusion criteria, 30 studies were selected for review. The radial forearm free flap is the preferred technique for total phalloplasty; however, other techniques including the fibular osteocutaneous flap, anterolateral thigh flap, latissimus dorsi flap, scapular free flap, and abdominal flap are described. Background, indications, and preoperative and postoperative care are also discussed.

CONCLUSIONS

Total penile reconstruction can provide functional, aesthetic, and psychosocial benefits to the patient. Use of the radial forearm free flap has been proposed as the gold standard; however, the wide range of potential complications associated with phalloplasty warrants an individualized approach to each patient.

Epidemiology of Genitourinary Injuries among Male U.S. Service Members Deployed to Iraq and Afghanistan: Early Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project

PURPOSE

In this study we report the number, nature and severity of genitourinary injuries among male U.S. service members deployed to Operations Iraqi Freedom and Enduring Freedom.

MATERIALS AND METHODS

This retrospective cross-sectional study of the Department of Defense Trauma Registry used ICD-9-CM codes to identify service members with genitourinary injuries, and used Abbreviated Injury Scale codes to determine injury severity, genitourinary organs injured and comorbid injuries.

RESULTS

From October 2001 to August 2013, 1,367 male U.S. service members sustained 1 or more genitourinary injuries. The majority of injuries involved the external genitalia (1,000, 73.2%), including the scrotum (760, 55.6%), testes (451, 33.0%), penis (423, 31%) and/or urethra (125, 9.1%). Overall more than a third of service members with genitourinary injury sustained at least 1 severe genitourinary injury (502, 36.7%). Loss of 1 or both testes was documented in 146 men, including 129 (9.4%) unilateral orchiectomies and 17 (1.2%) bilateral orchiectomies. Common comorbid injuries included traumatic brain injury (549, 40.2%), pelvic fracture (341, 25.0%), colorectal injury (297, 21.7%) and lower extremity amputations (387, 28.7%).

CONCLUSIONS

An unprecedented number of U.S. service members sustained genitourinary injury while deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Further study is needed to describe the long-term impact of genitourinary injury and determine the potential need for novel treatments to improve sexual, urinary and/or reproductive function among service members with severe genital injury.